Provider Demographics
NPI:1013917368
Name:GREEN, ELIZABETH EARLE (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:EARLE
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3921 GOLDFINCH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2926
Mailing Address - Country:US
Mailing Address - Phone:619-260-0335
Mailing Address - Fax:619-260-1682
Practice Address - Street 1:3921 GOLDFINCH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2926
Practice Address - Country:US
Practice Address - Phone:619-260-0335
Practice Address - Fax:619-260-1682
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY15277103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY15277OtherLICENSE
CAPSY152770Medicaid
CAOPL152770OtherBLUE SHIELD
CAPSY15277OtherLICENSE